Assessing the penetration, fidelity, and birth outcomes associated with the 2016 WHO antenatal care policy across states in Nigeria

The World Health Organization (WHO) rolled out the 2016 antenatal care (ANC) policy, including the eight-visit ANC (8vANC) recommendation, to improve women's ANC uptake and ensure positive pregnancy experience. Following the adoption and implementation of the 2016 WHO ANC policy by the Nigerian Federal Ministry of Health in 2017, a national cross-sectional survey conducted in 2021 indicated significant differences in state-level utilization rates of 8vANC. Using a combination of an implementation research approach and multilevel analysis, this study examined the underlying determinants of both the utilization behaviors and selected birth outcomes associated with the 2016 WHO ANC policy in Nigeria.With a post-implementation sample obtained from the Multiple Indicator and Cluster Survey (MICS6) 2021, Aim 1 focused on assessing the underlying determinants attributable to the observed differences in 8vANC utilization. The outcome was defined as the penetration of the WHO 8vANC policy and was measured as the proportion of women who used a minimum of 8vANC out of the total number of women who had live births within two years before the 2021 MICS6. The findings indicated that while women who self-reported their perception of life satisfaction as ‘very happy’ and ‘somewhat happy’ had increased odds of 8vANC utilization across states, the perception of wife beating justified ‘if she goes out without telling husband’ had reduced odds on the penetration of the 8vANC. Aim 2 examined the determinants associated with fidelity to five selected ANC components (the timing of first ANC visit, blood pressure measurement, blood sample test, urinalysis, and tetanus vaccination) among women who completed 8vANC. The findings indicated that 99.7% initiated their first ANC visit within 12 weeks of gestation and the rate of concordance with the five selected ANC components was 83.7%, on average. Aim 3 examined the association of C-sections, low birth weight (LBW), and perinatal death with penetration and fidelity to the policy by generating a main fixed effect labeled as penetration-fidelity. The findings revealed that penetration-fidelity was positively associated with LBW, negatively associated with perinatal death, and insignificantly associated with C-section.